- Are People With Bipolar Disorder Dangerous?
- Untreated Bipolar Disorder Can Lead to Increased Risk of Domestic Violence
- What Is Bipolar Disorder Exactly?
- Bipolar Disorder and Domestic Violence
- Successful Bipolar Disorder Treatment
- Three Bipolar Disorder Symptoms No One Wants to Talk About
- The three symptoms below represent the side of bipolar disorder we all know is there, but we rarely want to let the public know exists.
- Violence in Bipolar Disorder
- Bipolar disorder and violent crime
- What kind of research was this?
- What did the research involve?
- What were the results?
- How did the researchers interpret the results?
- Links to the headlines
- Links to the science
- Mental illness and violence
- Assessing risk of violence
- Preventing violence
- My bipolar depression cycles are the worst parts of me
- Bipolar depression is a war of the mind
- Bipolar I forces you to live at the extremes
- The less control you have, the more you will cycle between depression and mania
- Concerned about Bipolar Disorder?
- Bipolar I disorder is often accompanied by other illnesses
- Seasonal Affective Disorder (SAD) often co-occurs with bipolar disorder.
- Having bipolar I increases your risk of attempting suicide and inflicting self-harm
- You should ask questions and do your homework when your doctor prescribes you medication
- Bipolar I doesn’t have to define you
- Myth 1: Bipolar disorder is a severe mental illness
- Myth 2: Mood swings always mean bipolar disorder
- Myth 3: Depression and mania are cyclical
- Myth 4: Bipolar disorder is difficult to treat
- Where to get help
- Bipolar Disorder (Manic Depressive Illness or Manic Depression)
- What Is It?
Are People With Bipolar Disorder Dangerous?
People with any mental illness are often labeled as potentially violent, even if they have no history of violence or any apparent violent tendencies. This stigma can be particularly strong when applied against people with bipolar disorder, which can be alarming and misunderstood by others.
The truth about the risk of violence among bipolar people is complicated. By some estimates, between 11 and 16 percent of people with bipolar disorder have had a violent episode. These typically occur during extreme moods or because of drug or alcohol use. But there are many people with bipolar disorder who are never violent. Knowing which bipolar symptoms of depression and mania to watch out for may help avoid dangerous situations.
“There has been a long-standing expectation that mentally ill individuals are more likely to perpetrate violent acts. However, large population studies suggest that mental illness alone does not increase the likelihood of violence,” says psychiatrist Michael Peterson, MD, PhD, an assistant professor in the department of psychiatry at the University of Wisconsin School of Medicine and Public Health in Madison.
Factors that Increase the Risk of Violence
While having bipolar disorder alone does not make violence more likely, there are situations which, when combined with bipolar disorder, can increase the risk of violence. These include:
- Drug or alcohol abuse. Substance use is common among people with mental illness. Unfortunately, drugs and alcohol can make violent episodes more likely — and may also put people in situations where violence is the norm.
- High emotional stress. Periods of great emotional stress or distress, such as losing a loved one or ending a relationship, may trigger mood swings that can increase the risk of violence.
The Danger of Self-Harm
In fact, people with bipolar disorder may be more of a threat to themselves than anyone else in their lives. Innocent bystanders may be worrying unnecessarily about their own safety when the reality is that bipolar disorder can lead to a lot more damage to the person living with it.
These risks include:
- Suicide or attempted suicide. Rates of suicide are significantly higher among people with bipolar disorder than their peers. People with bipolar disorder are close to nine times more likely to commit suicide than their peers.
- Drug or alcohol abuse. “People with bipolar are also at higher risk of developing substance abuse or dependence,” explains Dr. Peterson, adding that bipolar patients are at higher risk of having manic or depressed episodes when they are abusing drugs or alcohol. Data suggest that 46 percent of people with bipolar disorder are dependent on alcohol and that 41 percent are dependent on other drugs.
- Cutting. Occasionally, people with bipolar disorder cut or hurt themselves deliberately.
- Non-physical damage. During manic periods, bipolar people may do a lot of “violence” to their own financial situation, relationships, and other elements of their lives as they act on impulse and pursue high risk behaviors.
If you have a loved one with bipolar disorder, Peterson says, “Be vigilant for signs of either depression or mania. Particularly during depressed or mixed episodes, when there are concurrent symptoms of both mania and depression, a real concern is suicidal thoughts and attempts.”
Peterson says signs of depression to watch out for include being more withdrawn or sad, or sleeping more than usual. Warning signs of mania include talking more, becoming more active, sleeping less, and becoming more outgoing and impulsive. Mania can lead to violence because of increased irritability and poor impulse control.
Peterson advises having “frank discussions” about these symptoms with the person who has bipolar disorder and then notifying her doctors or therapists, or even the police, if you continue to be concerned about your safety or the safety of the person with bipolar disorder. Effective medications are available that can help reduce the risk of violence and control the bipolar symptoms if urgent situations are identified in a timely way.
Untreated Bipolar Disorder Can Lead to Increased Risk of Domestic Violence
The idea that people suffering from mental disorders are automatically more violent than the general population has been established as a myth, a stereotype that, thankfully, is being shattered. And yet, there are several aspects of untreated bipolar disorder than can lead to an increased risk of domestic violence.
This is a confusing and frightening situation with emotional and physical repercussions for all involved, so it’s important to understand a few basic facts about bipolar disorder and why treatment is a significant, important step who anyone who might be struggling.
What Is Bipolar Disorder Exactly?
The brain uses an intricate system of chemical signals to manage emotional functions in the central nervous system.
Tiny changes in the level of these chemicals are directly related to the following critical functions:
- Positive and negative feelings
- The formation and recollection of memories
- Impulse control
- Anxiety and stress management
When individuals suffer from an imbalance or deficiency in this chemical system, they may experience moments marked by extreme depression and times of emotional mania.
Some of the most common symptoms of depression include: emotional numbness, persistent sadness, crying, lack of motivation, feelings of hopelessness and despair and suicidal thoughts, words or actions, while common symptoms of bipolar mania have a few distinct differences.
In addition to emotional outbursts, you might notice a recklessness or lack of responsibility in making decisions, including those that involve sexual behavior, spending money or using drugs and alcohol. Those dealing with bipolar mania may find little need for sleep, lack personal culpability for their actions, they may verbally abuse others and have an irrationally elevated mood.
Bipolar individuals tend to move from one of these emotional extremes to the other. They often fail to receive treatment because during depressive episodes they don’t believe there is any hope to feel better, and during manic times they don’t feel that they need any help. Spouses and loved ones tend to live with a combination of fear and uncertainty as a result.
Bipolar Disorder and Domestic Violence
Individuals with untreated bipolar disorder are at an increased risk for violent behavior for the following reasons:
- Substance abuse often fuels domestic violence.
- Mania can cause impulse control disorders.
- Reckless sexual behavior can cause injury to the bipolar person’s partner.
- Major depression can cause suicidal thoughts or actions.
Because of the constantly volatile nature of the disease, bystanders are often unsure how to prepare themselves and how to encourage their loved one to get help.
Successful Bipolar Disorder Treatment
While there is no known cure for bipolar disorder, mental health professionals have discovered several very effective treatment tools, including medical care and various forms of counseling, that can reduce symptoms significantly.
Also know that it is not uncommon for the partner of a bipolar individual to resort to holding an intervention in order to convince his or her partner that help is needed and available.
If you are living with a bipolar individual and are concerned for your safety or the safety of your loved one, please call our toll-free helpline at 615-490-9376. Our admission counselors can help you understand the implications and risks associated with this disease and can connect you with excellent recovery resources. If you feel that you are in immediate danger, please dial 911 before doing anything else.
By Christa Banister, Contributing Writer
Three Bipolar Disorder Symptoms No One Wants to Talk About
By Julie A. Fast
- Post Views: 1,142,596 Views
The three symptoms below represent the side of bipolar disorder we all know is there, but we rarely want to let the public know exists.
I know how important it is to protect the reputation of bipolar disorder in the general public. We don’t want people thinking we are dangerous, scary, crazy people who can’t be trusted. But I do feel we need to own up to the fact that certain mood swings DO cause the behaviors we want to sweep under the carpet. The three symptoms below represent the side of bipolar disorder we all know is there, but we rarely want to let the public know exists. This is only an opinion of course, but I’m truly interested to know if you feel the same.
#1 Dangerous, Aggressive and Violent Behavior in Bipolar Disorder
I work with parents and partners of those with bipolar disorder. In the majority of situations, people who are in a strong dysphoric manic episode can be dangerous, aggressive, and violent. Physical assault and weapons are not uncommon. Many men go to jail because of this behavior when they actually need psychiatric help. People who are mild-mannered and kind when well, both men and women, get superhuman strength along with the aggression—ripping a sink out of the wall, punching through windows, throwing chairs and other dangerous behaviors are not uncommon.
Families and partners suffer in silence because they are scared to tell anyone about what really goes on at home.
I have violent thoughts when the dysphoric mania is raging. I used to chase down cars if the driver flipped me off or made a strange face. It is not my goal to scare anyone reading this blog. It’s my goal that we are honest about these hidden and pushed-under-the-rug symptoms of bipolar disorder.
The solution is management. People with bipolar disorder do not have these symptoms unless the mood swings are raging. Prevent the mood swings, and you can prevent the dangerous, aggressive, and violent behavior.
#2 Psychosis in Bipolar Disorder
I have rapid cycling bipolar II disorder, with psychotic features. I experienced undiagnosed psychotic symptoms from age 19 to 31 when I was finally diagnosed. I’ve had hallucinations and delusions all of my adult life. What scares me is that no one and I mean no one educated me about psychosis when I was diagnosed. It was as if the symptoms didn’t exist. When I learned the extent of my psychosis, I was appalled that I had lived with it for so long. My symptoms were mostly visual hallucinations and paranoid delusions. I didn’t know that others didn’t have them as well! If you have bipolar I disorder, there is a 70% chance of full-on psychosis when you are in a full-blown manic episode. This psychosis can be very bizarre and mimic schizophrenia. The difference? People with bipolar disorder only have psychosis during a manic or depressed mood swing. There is no psychosis outside of depression or mania. If a person has psychosis in between episodes, this is not bipolar disorder, but another mental health condition. Do you or your loved ones have psychosis? If bipolar disorder is involved, psychosis could be involved as well.
#3 Cognitive Impairment in Bipolar Disorder
Many people find this scary. We already have bipolar disorder, does this mean we have memory problems as well? Maybe. Cognitive impairment from memory lapses, forgetting appointments, being unable to remember information, and experiencing brain fog during certain episodes is common! If you have bipolar, you’ve probably felt the sluggish brain that comes with depression. If you have mania, you have probably tripped over your words, said things you didn’t mean, and had trouble thinking in order.
My cognitive symptoms visit me daily. I’m not able to remember dates and numbers and need help with calendars and appointments. Mine got worse after intense therapy I had for severe depression. It’s something I find distressing, but it’s easy to manage. I want us to be open about cognitive issues. This is the only way we can get help! Mine tend to linger all of the time, but they get worse with mood swings. A perfect example of this: I am supposed to put this blog up by midnight the day of my blog slot. I reminded myself all day yesterday to put it up, but still managed to go to sleep without posting it on time. I have to live with these symptoms and even though a few things slip through, I do control the majority of my minor memory problems with a good support system!
Here’s the Good News—Yes, There Is Good News!
Bipolar disorder is an episodic illness. We have all of our symptoms while in a mood swing. This means we are STABLE when we are not in a mood swing. The symptoms I list above usually go away when the illness is successfully managed. It can take regular monitoring for those of us who have daily symptoms. Others who have long breaks between mood swings may even forget the symptoms even existed. This is why we must have a management plan that can recognize the dangerous, aggressive, and violent behavior, psychosis, and cognitive impairment as soon as it begins.
I know we want to protect our reputations around this illness. We don’t want to be seen as different or freaks. But I ask that within our community, we get brutally honest about what really happens to those of us with the illness. It’s the ONLY way to stop the symptoms and make them stay away forever!
Violence in Bipolar Disorder
1. Widom CS. Child abuse, neglect, and violent criminal behavior. Criminology. 1989;27:251-271.
2. Pollock VE, Briere J, Schneider L, et al. Childhood antecedents of antisocial behavior: parental alcoholism and physical abusiveness. Am J Psychiatry. 1990;147:1290-1293.
3. Bryer JB, Nelson BA, Miller JB, Krol PA. Childhood sexual and physical abuse as factors in adult psychiatric illness. Am J Psychiatry. 1987;144:1426-1430.
4. Kessler RC, Davis CG, Kendler KS. Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey. Psychol Med. 1997;27:1101-1119.
5. Brown GR, Anderson B. Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. Am J Psychiatry. 1991;148:55-61.
7. Leverich GS, McElroy SL, Suppes T, et al. Early physical and sexual abuse associated with an adverse course of bipolar illness. Biol Psychiatry. 2002;51:288-297.
8. Brown GR, McBride L, Bauer MS, Williford WO; Cooperative Studies Program 430 Study Team. Impact of childhood abuse on the course of bipolar disorder: a replication study in U.S. veterans. J Affect Disord. 2005;89:57-67.
9. Garno JL, Goldberg JF, Ramirez PM, Ritzler BA. Impact of childhood abuse on the clinical course of bipolar disorder . Br J Psychiatry. 2005;186:121-125.
10. Daruy-Filho L, Brietzke1 E, Lafer B, GrassiOliveira R. Childhood maltreatment and clinical outcomes of bipolar disorder. Acta Psychiatr Scand. 2011;124:427-434.
11. Etain B, Mathieu F, Henry C, et al. Preferential association between childhood emotional abuse and bipolar disorder. J Trauma Stress. 2010;23:376-383.
12. Conus P, Cotton S, Schimmelmann BG, et al. Pretreatment and outcome correlates of past sexual and physical trauma in 118 bipolar I disorder patients with a first episode of psychotic mania. Bipolar Disord. 2010;12:244-252.
13. Brodsky BS, Oquendo M, Ellis SP, et al. The relationship of childhood abuse to impulsivity and suicidal behavior in adults with major depression. Am J Psychiatry. 2001;158:1871-1877.
15. Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. 2nd ed. New York: Oxford University Press; 2007.
16. Volavka J. Violence in schizophrenia and bipolar disorder. Psychiat Danub. 2013;25:24-33.
17. Pulay AJ, Dawson DA, Hasin DS, et al. Violent behavior and DSM-IV psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008;69:12-22.
19. Carpiniello B, Lai L, Pirarba S, et al. Impulsivity and aggressiveness in bipolar disorder with co-morbid borderline personality disorder. Psychiatry Res. 2011;188:40-44.
20. Swann AC. Neuroreceptor mechanisms of aggression and its treatment. J Clin Psychiatry. 2003;64(suppl 4):26-35.
22. Haggård-Grann U. Assessing violence risk: a review and clinical recommendations. J Couns Dev. 2007;85:294-302.
23. Garno JL, Gunawardane N, Goldberg JF. Predictors of trait aggression in bipolar disorder. Bipolar Disord. 2008;10:285-292.
24. Pearlman LA, Courtois CA. Clinical applications of the attachment framework: relational treatment of complex trauma. J Trauma Stress. 2005;18:449-459.
25. Amore M, Menchetti M, Tonti C, et al. Predictors of violent behavior among acute psychiatric patients: clinical study. Psychiatry Clin Neurosci. 2008;62:247-255.
26. Kinoshita Y, Shimodera S, Nishida A, et al. Psychotic-like experiences are associated with violent behavior in adolescents. Schizophr Res. 2011;126:245-251.
27. Swann AC. Treatment of aggression in patients with bipolar disorder. J Clin Psychiatry. 1999;60(suppl 15):25-28.
28. Grisso T, Davis J, Vesselinov R, et al. Violent thoughts and violent behavior following hospitalization for mental disorder. J Consult Clin Psychol. 2000;68:388-398.
Bipolar disorder and violent crime
What kind of research was this?
This was a population-based, longitudinal cohort study that compared the risk of violent crime in people with bipolar disorder with the risk in the general population and also with siblings unaffected by the disorder. The researchers also carried out a systematic review and meta-analysis which included previous research in this area.
The researchers point out that various adverse health outcomes have been associated with bipolar disorder, including suicide, homelessness and repeat offending. But the evidence for any association between bipolar disorder and violent crime is less clear. Their aim, they say, was to quantify any possible risk of violent crime associated with bipolar disorder, and to adjust for other factors such as social class and income, early environment and genetics, and to examine the effect of substance abuse.
What did the research involve?
The researchers compared the rate of violent crime in 3,743 individuals diagnosed with bipolar disorder who were cared for in Swedish hospitals between 1973 and 2004 with that of 37,429 individuals in the general population. They also compared rates of violent crime in people with bipolar disorder with their unaffected siblings.
To identify these groups the researchers used national population-based registries in Sweden: the Hospital Discharge Registry (HDR), the National Crime Register, the national census from 1970 and 1990 and the Multi-Generation Register.
To be included in the study, patients had to have been discharged from hospital with a diagnosis of bipolar disorder according to internationally accepted definitions, on at least two separate occasions between 1973 and 2004, and had to be at least 15 years old at the start of the study. The researchers also extracted data for each of these patients about diagnoses of alcohol and drug abuse or dependence.
Researchers also identified two comparison groups of individuals who had never been hospitalised with bipolar disorder during the study period. The first was a random sample of approximately 10 individuals in the general population who were matched on birth year and sex for each individual with bipolar disorder. The second was made up of 4,059 siblings of a subgroup of 2,570 individuals with bipolar disorder. Both comparison groups included people who may have had a history of substance abuse.
Researchers also retrieved data on all convictions for violent crime from 1973 to 2004 for all individuals aged 15 (the age of criminal responsibility in Sweden) and older. Definition of violent crime included homicide, assault, robbery and rape.
They also took into account sociodemographic factors such as income, marital and immigrant status.
Using validated statistical methods the researchers used this information to identify any association between violent crime and bipolar disorder, compared with the two control groups. Only violent crime after the second diagnosis of bipolar disorder was included.
They also carried out a systematic review and meta-analysis, with searches for studies in this area between 1970 and 2009.
What were the results?
The researchers found that:
- In the individuals with bipolar disorder, 8.4% committed violent crime compared with 3.5% in the general population (adjusted OR 2.3; 95% confidence interval 2.0 to 2.6) and 5.1% of unaffected siblings (aOR 1.1; 95% CI 0.7 to 1.6).
- In those with bipolar disorder, the risk of violent crime was mostly confined to patients with a history of substance abuse (aOR 6.4; 95% CI 5.1 to 8.1). Of the patients with bipolar disorder and severe substance abuse, 21.3% were convicted of violent crimes compared with 4.9% of those without substance abuse.
- Risk increase was minimal in patients with no history of substance abuse (aOR 1.3; 95% CI 1.0 to 1.5).
- There were no differences in violent crime rates by clinical subgroups (for example, manic versus depressive phases of the disorder, or psychotic versus non-psychotic).
The researchers’ systematic review identified eight previous studies in this area. A meta-analysis that included their own study found that the odds ratios for the risk of violent crime in individuals with bipolar disorder, ranged from 2 to 9.
How did the researchers interpret the results?
The researchers point out that while there is an increased risk of violent crime among individuals with bipolar disorder, most of the excess risk is associated with a history of substance abuse.
They also say that the increased risk of violent crime shown among the siblings of those with bipolar disorder weakens the relationship between a diagnosis of bipolar disorder and violent crime, and highlights the importance of genetic and early environmental factors.
Substance misuse is high in individuals with bipolar disorder, so substance abuse treatment in this group is likely to reduce the risk of violent crime.
This large well-conducted study has several strengths. Its size increases its statistical power and makes its conclusions more reliable. Its results are adjusted for possible confounders such as income. It also only included violent crime after diagnosis, which reduces the risk that hospital admission may have been triggered by a criminal conviction. The comparison population group was well matched for birth year and sex.
The authors note some limitations in its methods, which could mean the possibility that some individuals with bipolar disorder were missed and the effects of substance abuse may have been underestimated.
The study’s conclusion that bipolar disorder per se is not associated with violent crime is important, as is the strong association between bipolar disorder, substance misuse and violent crime. The findings suggest that there should be risk assessment for violent crime in patients with both bipolar and substance misuse and strengthens the case for improved treatment services for these people.
Analysis by Bazian
Edited by NHS Website
Links to the headlines
Mentally ill not more violent, says study
The Independent, 8 September 2010
Call to improve psychiatric help
Financial Times, 8 September 2010
Bipolar ‘not linked to violence’
BBC News, 8 September 2010
Substance abuse, not mental illness, causes violent crime
The Guardian, 8 September 2010
Links to the science
Fazel S, Lichtenstein P, Grann M et al.
Bipolar Disorder and Violent Crime: New Evidence From Population-Based Longitudinal Studies and Systematic Review
Archives of General Psychiatry. 2010;67(9):931-938
Mental illness and violence
Published: January, 2011
Multiple interacting factors contribute to violent behavior.
Public opinion surveys suggest that many people think mental illness and violence go hand in hand. A 2006 national survey found, for example, that 60% of Americans thought that people with schizophrenia were likely to act violently toward someone else, while 32% thought that people with major depression were likely to do so.
In fact, research suggests that this public perception does not reflect reality. Most individuals with psychiatric disorders are not violent. Although a subset of people with psychiatric disorders commit assaults and violent crimes, findings have been inconsistent about how much mental illness contributes to this behavior and how much substance abuse and other factors do.
An ongoing problem in the scientific literature is that studies have used different methods to assess rates of violence — both in people with mental illness and in control groups used for comparison. Some studies rely on “self-reporting,” or participants’ own recollection of whether they have acted violently toward others. Such studies may underestimate rates of violence for several reasons. Participants may forget what they did in the past, or may be embarrassed about or unwilling to admit to violent behavior. Other studies have compared data from the criminal justice system, such as arrest rates among people with mental illness and those without. But these studies, by definition involving a subset of people, may also misstate rates of violence in the community. Finally, some studies have not controlled for the multiple variables beyond substance abuse that contribute to violent behavior (whether an individual is mentally ill or not), such as poverty, family history, personal adversity or stress, and so on.
The MacArthur Violence Risk Assessment Study was one of the first to address the design flaws of earlier research by using three sources of information to assess rates of violence. The investigators interviewed participants multiple times, to assess self-reported violence on an ongoing basis. They verified participants’ recollections by checking with family members, case managers, or other people familiar with the participants. Finally, the researchers also checked arrest and hospitalization records.
The study found that 31% of people who had both a substance abuse disorder and a psychiatric disorder (a “dual diagnosis”) committed at least one act of violence in a year, compared with 18% of people with a psychiatric disorder alone. This confirmed other research that substance abuse is a key contributor to violent behavior. But when the investigators probed further, comparing rates of violence in one area in Pittsburgh in order to control for environmental factors as well as substance use, they found no significant difference in the rates of violence among people with mental illness and other people living in the same neighborhood. In other words, after controlling for substance use, rates of violence reported in the study may reflect factors common to a particular neighborhood rather than the symptoms of a psychiatric disorder.
Several studies that have compared large numbers of people with psychiatric disorders with peers in the general population have added to the literature by carefully controlling for multiple factors that contribute to violence.
In two of the best designed studies, investigators from the University of Oxford analyzed data from a Swedish registry of hospital admissions and criminal convictions. (In Sweden, every individual has a unique personal identification number that allowed the investigators to determine how many people with mental illness were convicted of crimes and then compare them with a matched group of controls.) In separate studies, the investigators found that people with bipolar disorder or schizophrenia were more likely — to a modest but statistically significant degree — to commit assaults or other violent crimes when compared with people in the general population. Differences in the rates of violence narrowed, however, when the researchers compared patients with bipolar disorder or schizophrenia with their unaffected siblings. This suggested that shared genetic vulnerability or common elements of social environment, such as poverty and early exposure to violence, were at least partially responsible for violent behavior. However, rates of violence increased dramatically in those with a dual diagnosis (see “Rates of violence compared”).
Taken together with the MacArthur study, these papers have painted a more complex picture about mental illness and violence. They suggest that violence by people with mental illness — like aggression in the general population — stems from multiple overlapping factors interacting in complex ways. These include family history, personal stressors (such as divorce or bereavement), and socioeconomic factors (such as poverty and homelessness). Substance abuse is often tightly woven into this fabric, making it hard to tease apart the influence of other less obvious factors.
Rates of violence compared
Percentage of people convicted of at least one violent crime, 1973–2006
Source: Fazel S, et al. Journal of the American Medical Association. May 20, 2009.
Percentage of people convicted of at least one violent crime, 1973–2004
Source: Fazel S, et al. Archives of General Psychiatry. September 2010.
Assessing risk of violence
Highly publicized acts of violence by people with mental illness affect more than public perception. Clinicians are under pressure to assess their patients for potential to act in a violent way. Although it is possible to make a general assessment of relative risk, it is impossible to predict an individual, specific act of violence, given that such acts tend to occur when the perpetrator is highly emotional. During a clinical session, the same person may be guarded, less emotional, and even thoughtful, thereby masking any signs of violent intent. And even when the patient explicitly expresses intent to harm someone else, the relative risk for acting on that plan is still significantly influenced by the following life circumstances and clinical factors.
History of violence. Individuals who have been arrested or acted violently in the past are more likely than others to become violent again. Much of the research suggests that this factor may be the largest single predictor of future violence. What these studies cannot reveal, however, is whether past violence was due to mental illness or some of the other factors explored below.
Substance use. Patients with a dual diagnosis are more likely than patients with a psychiatric disorder alone to become violent, so a comprehensive assessment includes questions about substance use in addition to asking about symptoms of a psychiatric disorder.
One theory is that alcohol and drug abuse can trigger violent behavior in people with or without psychiatric disorders because these substances simultaneously impair judgment, change a person’s emotional equilibrium, and remove cognitive inhibitions. In people with psychiatric disorders, substance abuse may exacerbate symptoms such as paranoia, grandiosity, or hostility. Patients who abuse drugs or alcohol are also less likely to adhere to treatment for a mental illness, and that can worsen psychiatric symptoms.
Another theory, however, is that substance abuse may be masking, or entwined with, other risk factors for violence. A survey of 1,410 patients with schizophrenia participating in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, for example, found that substance abuse and dependence increased risk of self-reported violent behavior fourfold. But when the researchers adjusted for other factors, such as psychotic symptoms and conduct disorder during childhood, the impact of substance use was no longer significant.
Personality disorders. Borderline personality disorder, antisocial personality disorder, conduct disorder, and other personality disorders often manifest in aggression or violence. When a personality disorder occurs in conjunction with another psychiatric disorder, the combination may also increase risk of violent behavior (as suggested by the CATIE study, above).
Nature of symptoms. Patients with paranoid delusions, command hallucinations, and florid psychotic thoughts may be more likely to become violent than other patients. For clinicians, it is important to understand the patient’s own perception of psychotic thoughts, because this may reveal when a patient may feel compelled to fight back.
Age and gender. Young people are more likely than older adults to act violently. In addition, men are more likely than women to act violently.
Social stress. People who are poor or homeless, or otherwise have a low socioeconomic status, are more likely than others to become violent.
Personal stress, crisis, or loss. Unemployment, divorce, or separation in the past year increases a patient’s risk of violence. People who were victims of violent crime in the past year are also more likely to assault someone.
Early exposure. The risk of violence rises with exposure to aggressive family fights during childhood, physical abuse by a parent, or having a parent with a criminal record.
The research suggests that adequate treatment of mental illness and substance abuse may help reduce rates of violence. For example, in one study, the CATIE investigators analyzed rates of violence in patients who had earlier been randomly assigned to antipsychotic treatment. (Patients’ own recollections were double-checked with family members.) This study found that most patients with schizophrenia who took antipsychotics as prescribed were less likely to be violent than those who did not. An exception to this general trend occurred in participants who were diagnosed with a conduct disorder during childhood. No medication proved better than the others in reducing rates of violence, but this study excluded clozapine (Clozaril).
This is important because both the CATIE investigators and other researchers cite evidence that clozapine appears more effective than other psychotics in reducing aggressive behavior in patients with schizophrenia and other psychotic disorders. One study found, for example, that patients with a diagnosis of schizophrenia or another psychotic disorder who were treated with clozapine had significantly lower arrest rates than those taking other drugs. The study was not designed to determine whether this was due to the drug itself or the fact that clozapine treatment requires frequent follow-ups that might encourage patients to continue taking it as prescribed.
Indeed, as with psychiatric treatment in general, medication treatment alone is unlikely to reduce risk of violence in people with mental illness. Interventions ideally should be long-term and include a range of psychosocial approaches, including cognitive behavioral therapy, conflict management, and substance abuse treatment.
Of course, this sort of ideal treatment may be increasingly difficult to achieve in the real world, given reductions in reimbursements for mental health services, ever-shorter hospital stays, poor discharge planning, fragmented care in the community, and lack of options for patients with a dual diagnosis. The Schizophrenia Patient Outcomes Research Team (PORT) guidelines, for example, outlined the type of multimodal treatment necessary to increase chances of full recovery. Most patients with schizophrenia do not receive the kind of care outlined in the PORT recommendations. Solutions to these challenges will arise not from clinicians, but from policy makers.
Siever LJ. “Neurobiology of Aggression and Violence,” American Journal of Psychiatry (April 2008): Vol. 165, No. 4, pp. 429–42.
For more references, please see www.health.harvard.edu/mentalextra.
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Oct. 9, 2003 — Call it bipolar disorder. Call it manic depression. It’s the same thing, and it’s a serious mental illness that can lead to substance abuse, violence, and suicide if not treated.
But most Americans — 78% — don’t know even the basics about bipolar disorder, according to a new survey.
“The impact of untreated bipolar disorder on a person’s life is huge,” says Richard C. Birkel, PhD, in a news release. Birkel is executive director of The Nation’s Voice on Mental Illness, which commissioned the study along with Abbott Laboratories.
The telephone survey of 1,004 Americans — including 275 college students — was released today.
“Overall, Americans do not perceive mental illness to be as serious as other major diseases facing people in this country,” the report states.
- Forty-eight percent of the nation can identify schizophrenia as a mental illness, where as only 22% of people surveyed identified bipolar as a mental illness.
- Seventy-eight percent failed to name bipolar disorder and could not associate it with any of the risks, such as substance abuse and suicide.
- Almost four out of 10 (38%) people could not think of a single symptom associated with bipolar disorder.
- On a 100-point scale, where 100 is most serious, the nation as a whole rates mental illness as a 67 in terms of seriousness compared with other illnesses; 35- to 54-year-old women rate it slightly more serious than the rest of the nation.
- People over age 55 are least aware of bipolar disorder.
Bipolar disorder is caused by imbalances in brain chemicals and affects more than 2 million Americans. Though each case is different, the disorder usually involves periods of mania, followed by depression, with normal moods in between — hence, the name manic depression.
The mood swings can last for hours, days, weeks, even months.
Though there is no cure for bipolar disorder, it is a treatable and manageable illness, experts say. Medication is an essential part of treatment, to stabilize mood swings. With a therapist’s help, people can understand their illness better and develop skills to cope with stresses that trigger mood swings.
Because doctors don’t always understand bipolar disorder/manic depression, many people don’t get the right treatment.
My life living with bipolar I started on cold November night. It was a few days before Thanksgiving in 2007. I had tried to take my life by overdosing on my sleeping medication, and I was in a lot of pain. For a year and a half before this event, I had been living with one of the worst depression cycles of my life. It took almost three years after my attempted suicide for my depression cycle to finally reach its end. When I was diagnosised with bipolar I in 2007, I didn’t want to believe that there was something wrong with me. It took me three years of getting lost in the darkest parts of my depression and three suicide attempts before I started to make positive changes in my life.
It’s not easy living with bipolar I, but here are some things I’ve learned throughout my struggle. If you also have bipolar I, you may want to consider sharing these points with your own friends and family to help them understand what you are dealing with.
My bipolar depression cycles are the worst parts of me
Depression cycles always feature the worst parts of my personality. I am the worst version of myself. Depression cycles can last for years—my longest lasting from 2006 to 2010. In that span, I tried to take my life three different times—2007, 2008, and 2010. After therapy and a more aggressive look at my depression and anxiety, I started to learn to limit my depression cycles to months, then weeks, and, now, just days. The last time I entered this cycle was Christmas week of 2017 and it lasted just four days. I haven’t had one since. Bipolar depression cycles might be the worst parts of me, but with time, I’ve learned how to control them and how to help myself with the help of a mental health professional
Bipolar depression is a war of the mind
Many people go through depression, and everyone experiences deep sadness at times, but bipolar depression is a war of the mind that people with bipolar I disorder will battle over the course of their lives. You fight battles with depression over the course of weeks, months, and even years but the war will always be there in your life. There will always be battles in my mind. It’s how you limit those battles that truly makes a difference.
Bipolar I forces you to live at the extremes
With bipolar depression and mania, you live with extreme mood swings. This is the major difference between bipolar I and bipolar II. I learned to cut back my cycles by learning how to recognize my triggers and how to respond to them. For instance, sometimes I wake up and don’t want to get out of bed for several consecutive days at a time. It’s the same with mania. My mania was often defined by racking up credit card debt and reckless behavior. My thoughts when manic were often running a million miles a minute in my head, and I could go days without sleep. The crash was always the hardest for me.
The less control you have, the more you will cycle between depression and mania
Depression and mania can happen in an instant with bipolar I. I have had moments of peace in my life, sometimes for weeks, before something changes in my life that leads to rapid cycling. I can be on top of the world one moment and unable to get out of bed, the next. My manic side never likes to sleep so when mania runs its course, it always cycles back to depression—my default setting.
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Bipolar I disorder is often accompanied by other illnesses
I never struggled with anxiety until my diagnosis of bipolar I. Since then I have had to deal with a diagnosis of generalized anxiety disorder and social anxiety, otherwise known as social phobia. Other issues that I have experienced due to my medication include major weight gain and weight loss at various stages of my life. Insomnia is a major factor that accompanies my daily struggles with bipolar I. I have also developed prediabetes.
Seasonal Affective Disorder (SAD) often co-occurs with bipolar disorder.
My official diagnosis is bipolar I with a seasonal component. What that means is my depression hits epic levels for during the months of November to March. As a result, I can be in a really bad depression cycle and it gets worse every year at the same time. I can feel the changes at the end of October as the season gets colder. As the temperature drops my depression increases and becomes a more prominent aspect of my daily life. In contrast, during the summer months, my depression is manageable, or even nonexistent.
Having bipolar I increases your risk of attempting suicide and inflicting self-harm
It is very easy to turn to self-harm when you live with bipolar I disorder. I turned to self-harm as a teen and in my early twenties to keep my suicidal thoughts at bay. It was easier to deal with physical pain than my emotional pain. When it still wasn’t enough I turned to suicide. I now advocate against suicide as a final option and want others living with bipolar I to know that suicide is never the answer. With the help of a mental health professional, you can start taking steps towards limiting your own depression cycles and finding healthy ways to cope with your symptoms.
You should ask questions and do your homework when your doctor prescribes you medication
Your medical team will look at what works for your bipolar I diagnosis but know that the side effects can be harsh. At the same time don’t be afraid to ask real questions. At the beginning of my diagnosis, I just took whatever my psychiatrist prescribed without knowing the long-term effects. Over the course of ten years, I have struggled mightily with my two important medications—Seroquel and Ativan. They both have harsh long-term issues as they are supposed to be used as short-term solutions.
Bipolar I doesn’t have to define you
It is true, bipolar I disorder is for life, but that doesn’t mean that it should define your every waking moment. I will always have the extreme depression cycles and the extreme mania episodes, but learning how to manage and continuously work on your mental health can change your outlook on life entirely. It is not a shameful thing to have a mental illness, and the sooner you realize that truth, the sooner you can move forward.
I thought when I was diagnosed with bipolar I disorder that my life had ended. For the three years that followed my mind was marred by extreme levels of depression. I could barely live with it. It took my last suicide attempt for me to wake up and finally accept help. The mistake I made was not believing that there was something seriously wrong with me. Even in the years after I accepted help, I still struggled. I finally started to get my life together in 2014, and I am close to finishing my bachelor’s degree. I have worked through my struggles by writing my blog, my memoir, and a couple of screenplays.
The one thing I want people to take away from my experience is to avoid making the mistakes I did by turning to suicide and refusing to recognize that I needed help.
Get help. Believe in that help. Don’t hold back because resistance to the process will only make recovery harder. Recovery is possible, just not complete recovery. If you have bipolar I, you will have it for life, but you can learn to manage the extremes by using all the resources that you get your hands on. Never stop fighting. It’s always worth it.
Last Updated: Jun 4, 2019
Swinging wildly between euphoria and depression. Psychotic breaks. That’s how many people view bipolar disorder.
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But the reality is quite different, says psychiatrist Amit Anand, MD. Here, he upends common misconceptions about the brain disorder:
Myth 1: Bipolar disorder is a severe mental illness
“Many people believe that those with bipolar disorder are out of control and psychotic,” says Dr. Anand. “But we have learned over the last few decades that milder forms of bipolar disorder are much more common.”
The two main types of bipolar illness are bipolar I and bipolar II. Beyond that, bipolar illness takes many forms.
- In bipolar I, episodes of mania and depression can be quite severe.
- In bipolar II, depression may be severe, but the highs are much milder, do not truly impair function and may even make people more productive.
- In a much larger group of people, very mild or very few symptoms of mania occur for short periods of time — not enough to warrant a diagnosis. Some of these individuals are quite successful.
“Thus, most people with bipolar disorder live in the community and may never be admitted to a psychiatric hospital,” says Dr. Anand.
Myth 2: Mood swings always mean bipolar disorder
“Mood swings happen for many different reasons, including the weather, the menstrual cycle, common medications like steroids, and substance use,” says Dr. Anand.
Moodiness can also occur with medical illnesses such as hormone disorders, autoimmune diseases and neurological problems.
And mood swings occur with other brain illnesses, such as attention-deficit hyperactivity disorder (ADHD) and certain personality disorders.
What sets bipolar disorder apart? “The illness represents a change from the usual self,” explains Dr. Anand. “Also, depression lasts for several weeks at a time, and mania lasts for several days at a time. We look for a season of summer — not one hot day.”
Myth 3: Depression and mania are cyclical
People often assume that in bipolar disorder, periods of mania alternate regularly with periods of depression.
“In bipolar disorder, mood is more often chaotic, with random combinations of symptoms,” says Dr. Anand. “It is not cyclical.”
This helps fuel the turmoil that often unravels relationships with family, friends and coworkers — even in mild cases of bipolar disorder.
That is why treatment is so important.
Myth 4: Bipolar disorder is difficult to treat
“We have very, very effective treatments for bipolar illness,” says Dr. Anand. “Patients generally respond well to mood-stabilizing drugs, sometimes combined with antidepressants and/or drugs for mania.”
Psychotherapy is always recommended, he says, and offers many benefits by:
- Providing insight into the illness. “When people with bipolar disorder are depressed, they’re aware that they are in pain,” he says. “But when they are manic and feel very, very good, they don’t see a problem.”
- Teaching stress management strategies. Learning to manage stress, which can trigger mania and depression, is vital in bipolar disorder.
- Helping with problem-solving. People with bipolar disorder can learn how to deal better with family problems and work difficulties.
- Educating people about self-care. “When you have bipolar disorder, maintaining regular daily routines is critical,” says Dr. Anand. “But many people don’t sleep or eat at the right times, which causes more mood problems and creates a vicious cycle.”
Where to get help
If you suspect that you or someone you love may have bipolar disorder, get a full evaluation from a psychiatrist.
“Too often, bipolar disorder is not diagnosed, or it is mistaken for another problem,” says Dr. Anand. “Get one good diagnostic evaluation. Then, know that some very effective treatments can help you lead a normal life, like anyone else.”
Bipolar Disorder (Manic Depressive Illness or Manic Depression)
What Is It?
Published: March, 2019
Bipolar disorder, which used to be called manic depressive illness or manic depression, is a mental disorder characterized by wide mood swings from high (manic) to low (depressed).
Periods of high or irritable mood are called manic episodes. The person becomes very active, but in a scattered and unproductive way, sometimes with painful or embarrassing consequences. Examples are spending more money than is wise or getting involved in sexual adventures that are regretted later. A person in a manic state is full of energy or very irritable, may sleep far less than normal, and may dream up grand plans that could never be carried out. The person may develop thinking that is out of step with reality — psychotic symptoms — such as false beliefs (delusions) or false perceptions (hallucinations). During manic periods, a person may run into trouble with the law. If a person has milder symptoms of mania and does not have psychotic symptoms, it is called “hypomania” or a hypomanic episode.
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